Sustainability and transition in

the AMRO/PAHO Region Camilo Cid, MA, PhD

Regional advisor

Health Economics and Financing

Department of Health Systems and Services

Content

• Context

• What are we doing?

• PAHO´ strategy

• Developing a conceptual framework

• Advocacy

• Fiscal space and Costs studies

• Comments

2

3

Financial diagnosis of the Region…

ATG

ARG BAH BAR

BLZ BOL

BRA

CAN

CHI

COL

COR

CUB

DOM

RDO

ECU

GRD GUT

GUY

HAI HON

JAM

MEX

NIC

PAN

PAR

PER

SKN

SLA

SVG

SUR

TRT

USA

URU

VEN

OCDE

0

10

20

30

40

50

60

70

0 2 4 6 8 10 12

Ou

t o

f p

ock

et e

xpen

dit

ure

as

% o

f ex

pen

dit

ure

on

hea

lth

Public expenditure on health (%PIB)

Year 2014

4 of 5 surpass 6%

Source: Author with World Bank data-acceded 07/05/2016

4

0.0

5.0

10.0

15.0

20.0

25.0

30.0 Low Fiscal priority

Pu

blic

Exp

end

itu

re in

hea

lth

as

%

of

tota

l pu

blic

exp

end

itu

re t

ota

l

Source: World Health Organization Global Health Expenditure Database (acceded 2016)

Low Fiscal capacity

0

10

20

30

40

50

60

Tota

l pu

blic

exp

end

itu

re a

s %

of

GD

P

Other challenges in sustaining the

response: the health system

• Segmentation • Uncoordinated subsystems covering and serving different

“segments” of population

• Characteristic of LAC (MoH, SS, Private, Civil servants…..)

• Fragmentation • Service delivery (multiple actors, no integration)

• Care (promotion, prevention…continuity of care)

5

Content

• Context

• What are we doing?

• PAHO´strategy

• Developing a conceptual framework

• Advocacy

• Fiscal space and Costs studies

• Comments

6

Universal Healthcare: PAHO Regional

Strategy

2) Strengthening stewardship and governance

4) strengthening intersectoral coordination to address social determinants of health

3) Increasing and improving financing,

with equity and efficiency, and

advancing toward the elimination of direct payment…

1) Expanding equitable access comprehensive, quality, people-

and community-centered health

services

Source: PAHO/WHO HSS/HS

Developing a Conceptual Framework Authors – year and titles Main Objective Dimensions of

Sutainability

Factors/attributes that influence

sustainability

Factors that influence

integration

To which

programs do they

apply?

Main conclusions

Oberth & Whiteside

(2016)

What does sustainability

mean in the HIV and AIDS

response?

Conceptualize

sustainability in a context

of decrease of

international aid and

focused on the handover

of programs (3 examples

of transition)

1.Financial

2.Epidemiological

3.Political

4.Structural

5.Programatic

6.Human Rights

- Stable resource, from diverse

sources and efficiency.

- Stewardship and political good

will

- Social context (poverty, violence,

etc)

- Does the program make sense

within an integrated system

centered on PHC?

- Does it reach identified

populations?

X HIV/AIDS - Deal with the 6

dimensions

simultaneously

- Continuous

monitoring

- Foreign aid can still be

needed for particular

population groups.

Pluye, Potvin, Denis

(2004)

Making public health

programs last:

conceptualizing

sustainability

Under which

organizational structures

is sustainability

enhanced and when it

begins it is supported by

the institutional learning

process and new-

institutional

arrangements

(systematic review)

Centered in 2

dimensions:

1. Structural (social

structure and

organizational

characteristics)

2. Temporary

-Routine (memory, adaptation,

values, rules)

-Standarization

-Simultaneous processes of

planning and implementation

In my opinion

sustainablity and

intehration appear En

mi opinión

sostenibilidad e

integración aparecen

bastante mixed on both

dimensions (Routine

and standarization)

It is a general

framework,

despite that the

example focuses

on a promotion

program.

3 levels of sustainability

(non routine activities,

routine and standarized

routines)

Does not consider

sustainability as a final

stage, but

concomitant.

Shigayeva & Coker

(2014)

Communicable disease

control programs and

health systems: an

analytical approach to

sustainability

Propose a conceptual

framework to analize

sustainability and clear

the general notions over

sustainability and

integration, based on

systematic reviews.

1. What is it to be

sustained (resources,

performance or

objectives)

2. Which component

of the health care

system (one

intervention, one

organization, or the

system as a whole)

*resillience is

mentioned

-leadership (capacity to lead,

govern and manage) “champions”

-capacities (resources, planing,

implementation and evaluation

capacity) recursos y capacidad de

planificación,

-flexibility/adaptability

-interactions (relarelated to

integration and achievement of

the objectives)

- context (including donors that

promote verticality of programs

being a limitation)

They are not factors,

but levels of

integration: links,

coordination and full

integration within the

actors through the

continium of greater

formality in the

governance, sharing

responsiblities in joint

activities, and pooling

of the resources.

Regardless its

focus on

transmissible

diseases, it is still

applicable.

- Considers integration

as a determinant of

sustainability (not the

only)

-However, the role of

the integration fo the

various components

within a system, is

dependant on the

context and is difficult

to predict. 8

Strong health

systems

• Programatic sustainability

• Human rights

Equitable access to comprehensive and integrated

services

• Political and Epidemiological sust.

• Partnerships Strong stewardship and

governance

• Financial sustainability Sufficient, equitable and efficient financing

• Structural sustainability Intersectoral coordination

Proposed sustainability

dimensions

PAHO’s Fiscal space study for 14 countries

• Reasonable tax increases

and improved fiscal

priority can have

important effects

• Increasing the Public

Expenditure in Health

from these sources will

allow 8 more countries, to

achieve the indicator and

generate significant

progress in others.

Increase of PEH as % of GDP. Scenarios of fiscal expansion fiscal and two levels of fiscal priority.

Source: PAHO from Collecting Taxes Database 2010/2011, BID -CIAT y ECLAC (1) Current priority fiscal levels (2) Fiscal priority of 15 % of Total Public Expenditure.

PAHO’s Country-specific fiscal space

studies

• Bolivia

• There exists fiscal space and that economic growth is not enough,

• It is necessary to collect more and better,

• It is advisable to review tax expenditures to identify unjust or without

benefits for countries exemptions,

• There are arguments and space to increase specific health taxes

(alcohol and tobacco).

• Efficiency measures must accompany these efforts, given through three

main areas and arise from the strategy for universal access to health

and universal health coverage

• Credits and donations are not a politically viable source for governments.

• The study have to promote policy dialogue and ideally occur in a process

of change in the country

• Next study: Ecuador

• Peru

11

• Honduras

Final Comments

• Sustainability is achieved:

• Improving prevention and early detection of chronic diseases,

• Reducing the incidence of catastrophic illness, and

• Providing timely access to health services, specially at the first

level of care.

• With regard to financing,

• Eliminating payment at the point of delivery,

• Promoting the pooling of funds,

• Supporting integrated networks of service provision and

improving the quality of spending

• Incresing public financing

• In other words, integrating programs into the improved

health system